Inspection on 10/10/06 for 8 The Villas

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 The Villas 06/02/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 8 The Villas 8 The Villas West End Stoke-on-Trent Staffordshire ST4 5AH Lead Inspector Mr Berwyn Babb Key Announced Inspection 10 October 2006 01:30 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 8 The Villas Address 8 The Villas West End Stoke-on-Trent Staffordshire ST4 5AH 01782 847947 01782 412492 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (If applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Ronald Mark Snijders Elizabeth Claire Adams Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8) of places 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Number 8,The Villas, provides personal care and accommodation for eight service users with a learning disability, the minimum age for who is 30 years. The home, was opened in 1988, and is located in a residential area known as The West End, near the centre of the town of Stoke. Whilst quietly situated, it is very conveniently placed for access to all of the facilities of Stoke town. It is near to shops and pubs and is on a good public transport route. The home is provided in a large detached house that is intentionally preserved as being indistinguishable from other properties in the small un-adopted road. The accommodation consists of four single bedrooms and two shared bedrooms. None of the bedrooms have en-suite facilities. There are bathrooms on both floors, and separate W. C.’s conveniently situated around he home. There is ample communal and private space for the service users to enjoy, with a good standard of furniture, furnishings and fittings throughout. In addition to the spacious internal accommodation, the home has large and attractive rear gardens, with a smaller formal garden at the front. There was provision of outdoor seating in good quality high-grade garden furniture. The garden contains several fruit trees, a vegetable plot and a large greenhouse. The stated aims of the home are to provide a home for life for the service users based upon good management of care that promotes choice and normal lifestyles with strong community presence. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key inspection for the 2006/2007 period, had been prearranged to allow discussion with the proprietor of the implications of, and his response to, the fire officers report of the 17th of March. As the home had not received a copy of this report, and only had the rough notes taken by one of the members of staff on duty when Fire Officer Gallimore made his inspection, much time was spent with Mr Snijders (the provider) in reviewing its contents and discussing appropriate ways of ensuring relevant responses to the concerns highlighted. Mr Snijders agreed to obtain professional advice from the company currently undertaking fire safety servicing and training in the home, and to formulate an action plan.[Steps had already started on those issues recorded by the member of staff] During the afternoon two representatives of the community nursing team who had provided advice and assistance with the terminal care of one of the original residents of the home (who had died just over a fortnight previously) visited for a final bereavement session that was attended by the majority of the staff currently employed. They were overheard to be giving unqualified praise to the carers of this home for the way that they had made this gentlemans death as dignified, natural, and comfortable as was humanly possible. The inspector was deeply moved by the obvious grief of those staff who stayed on duty for the duration of the inspection, and who continued to care for the remaining residents with outstanding professionalism and devotion. Most residents spoke to the inspector and seemed relieved that a friend some of them had known for over 20 years was no longer in the pain and distress that they had witnessed him enduring. The home was comfortably furnished, well maintained, and proceeding with its everyday life, with residents undertaking suitable activities, as well as being assisted to keep health appointments, and to access the local community. What the service does well: This service continues to provide sympathetic monitoring and assistance in a domestic setting for up to eight adults with various degrees and types of Learning Disability. It places them within the community instead of excluded from it, and as a result, it magnifies the chances for them to appreciate non-institutional life. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Records demonstrated that full and proper assessments had been undertaken, and members of staff were seen using a variety of means of communication, and contracts had been individually personalised. EVIDENCE: During the afternoon the Inspector reviewed a person centred care plan relating to one of the residents. This demonstrated that prior to her admission to the home, the manager have obtained a summary of the care management assessment undertaken for this purpose. In addition to that, she had been to meet prospective new resident and had made her own observations on the ability of she and her staff to meet that persons assessed needs and stated choices. The lady herself had already told the Inspector that Beth (the registered care manager) had been to meet her before she came into the home, and had talked to her about the things that she liked to do, as well as those things that she was not able to do. Current fees for accommodation in this home are £468 per week. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The Person centred care plans detailed the assessed needs and choices of the residents, and how these were being met, how they were assisted to make decisions about their lives, and where some thing was assessed to be a risk, and the measures taken to reduce the risk and comply with choice. EVIDENCE: The Person Centred care Plan of a resident was reviewed in depth and taken to act as a sample of recording in this area. It contained a diary of usual events taking place in this persons life, as well as a full record of what actually happened on each day, and this was written in a non-judgemental, informative, and professional manner. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 10 Separate modules of the plan contained records of any accidents sustained, letters received, primary and tertiary medical appointments, (including regular sessions at the Well Woman clinic) risk assessments, activities of daily living, contact with relatives and friends, community access (including attendance at church) exercise programme, and daily health checks. The resident’s weight had been monitored regularly, and all care plans had been reviewed at the appropriate intervals. There was a clear indication of work being done to inform the residents about the likely consequences of various choices they face, so that they would be in a better position to make decisions for themselves about the way they lead their lives. Discussion with members of staff demonstrated an individual approach to the assessment of risk, and where some residents might be escorted so that they could undertake an action or access an element of the community; others had received education, training, or technical assistance, to enable them to do these things on their own. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents undertook appropriate and fulfilling activities or training, had access to, and a presence in, the local community, maintained and enlarged their family and friendship networks, were treated with dignity and respect, and benefited from the provision of a healthy diet in line with their needs and choices. EVIDENCE: A couple of residents gave the inspector at a brief itinerary of their attendance at local colleges, and chosen places of entertainment, both those open to the general public, and some that had been created specially to ensure that they had a protected space in which to play out their achievements. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 12 One resident was keen to talk about contact with the church, and several others about the good time that they have had a local club that provides a mixture of activities promoting a healthy lifestyle, and an enjoyable social life. One gentleman had been transported to see his mother in a residential home some miles away, and he was very happy about this telling the inspector: I love my mum . Another reported how she went regularly to see a friend, and receipt of letters from family members was one of the things observed in the care plan examined in depth. The interaction between residents and staff even during this all too brief visit to the home, showed the level of tolerance and professionalism that absorbs all the challenges of behaviours that were sometimes only predictable in their unpredictability, meeting them with a dignity and sensitivity that respected the rights and abilities of the resident. The residents enjoyed a cooked evening meal part way through this inspection, and several of them had undertaken tasks during its preparation, some in the kitchen, and some in the dining room area, and all expressed themselves well satisfied with the fruit of their labours. During an informal interview a member of staff compared the different dietary needs of residents, and how assistance from appropriate healthcare professionals guided them in helping residents to gain, maintain, or lose weight, as was most appropriate to their need. Further evidence of this was observed written in the care plan that was examined in detail, and in the positive regard showed to one person in response to their choosing a healthy option at teatime. Planned menus, and the record of what was actually prepared and served, demonstrated the variety of meals provided, and the success of the programme to widen the experience of residents in some fields, though staff remembered that some of the items introduced and received a definite thumbs down, and have not found their way into menu planning again. It was seen that the opportunity had been taken when nobody was rushing out of the house early at weekends, to have fuller and more leisurely breakfasts, with the introduction of such things as beans on toast, omelettes, croissants, tomatoes on toast, or bagels. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents were seen to be receiving personal support in a sensitive and dignified manner, to be having their physical and emotional health needs met, to be receiving their medication from people who had been approved to do this, and particularly, to be treated with love, dignity, thoughtfulness, and with services appropriate to their need, during the terminal phase of their life. EVIDENCE: A gentleman who had been in the home since it opened had recently been the subject of an agreed variation to allow him (with the support of all the other residents) to be accommodated in a former quiet room, which had been additional to the communal space requirements, during the terminal phase of his life. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 14 Discussion with residents and staff revealed how distressed they would have been if he had had to go somewhere else to die, and representatives of the community nursing team who had visited to support him remaining in the only home he knew, were present during the inspection, and praised both residents and staff for the nature of their response as he quietly slipped away from them. The distribution of medication to residents lacking the capacity to administer this for themselves, was observed, and felt to be professional and appropriate. Protocols for administration, and the receipt of training, were examined during a review of the relevant documentation, and the management and storage of medicines was felt to be appropriate for this home. The thorough nature of planned and responsive interventions to meet assessed and emerging physical and emotional needs, was observed through discussion and reference to care plans. There were entries for appointments with consultants, GPs, and nurses, as well as for tertiary preventative care of the eyes, teeth, feet, and hearing. Reference had been made to such other health professionals as speech and language therapists, occupational therapists, continence advisers, and infection control services. Each care plan had a matrix to be filled in regularly that recorded the monitoring of those medical assessment profiles that were relevant to the named individual. Sensitivity was seen in the way that staff promoted personal hygiene with residents during the inspection, and by the individual programs that were contained in the care plan. In the formal discussion with a member of staff, she was asked to describe how she would give a resident in a bath or a shower. Her answers demonstrated an appropriate knowledge of the medical conditions of the individual chosen, and the precautions that would need to be taken so as not to exacerbate this. She demonstrated an awareness of health and safety, and of the need to be aware of both the pleasure that a resident could gain from this care task, as well as the concerns that it may raise because of the intimate nature of being naked in front of another human being. She did not allow her concern for making this a pleasurable experience detract from the importance of allowing the resident to maintain their independence in doing everything that they were able to do, themselves. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. In a formal interview with a member of staff, a wide understanding of the issue of protection for vulnerable adults was forthcoming, as was an appreciation of the need to act as advocates for any residents who were concerned enough to want to make a complaint. EVIDENCE: An appropriately formatted version of the complaints procedure was seen in the care plan of one resident, and another copy had been framed and was hanging in the entrance hall. A carer who the inspector interviewed in depth, stated that with some residents they would have to assist them to further any complaint they made, but with others, they would depend on their knowledge of the body language being displayed, to detect that they had a concern in the first place. The agenda of the interview switched to the protection of vulnerable adults, where she displayed not only who her residents were at risk from (anybody) but also the various forms that abuse could take, and the procedure that she should follow should she ever suspect that somebody living at 8, The Villas, had been subjected to anything that was against their will. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, and 30. Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. A report had been received from a representative of the Staffordshire Fire and Rescue service that indicated to certain aspects of the building as it currently stood, would be unsatisfactory should there be a need to evacuate the building in a fire. EVIDENCE: This had been arranged as an announced inspection so that the proprietor and the inspector could meet together to discuss the content, and response to, fire officer Gallimores letter of the 17th of March 2006. Unfortunately the providers had not received a copy of this letter, so nearly half the time of the inspection was devoted to discussing its contents with Mr Snijders, and the implications that this had for his business. He readily agreed to obtain the services of somebody professionally versed in the language of, and legislation governing, fire officers, and to put together an action plan to meet the observations and recommendations detailed in the said letter. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 17 The only other area of concern that arose from this inspection was the discovery of two radiators that were without aguard, and were not of the low temperature surface style of manufacture. Other than the two above-mentioned concerns, this home is situated in a residential area and is in keeping with the houses surrounding it, with no outward indication that it is a care home. From a cursory visual examination, the exterior appeared to be in good condition, and an extensive tour of the interior showed this to be in a similar state of maintenance and decoration, and to be extremely comfortably furnished. Recent work to install a separate falls and gulley shower area into the downstairs bathroom has now been completed with the fitting of appropriate flooring, and one resident was particularly pleased with this, as he preferred being showered to being immersed in a domestic bath. The interiors of the bedrooms visited were all different, and all reflected an individual personality with its own likes and dislikes, and preferences for colour and style. None of the rooms have ensuite facilities, but a basin with both hot and cold running water was provided for washing in privacy. One gentleman had an astonishing display of medals on his wall, reflecting his prowess at various sporting gatherings, and he was only too pleased to talk about them. The home was clean and odour free throughout, and was looking very smart as the result of the recent round of redecoration. Cleaning schedules for the kitchen and other areas of the home were reviewed, and a visit was made to the laundry in the cellar, where all the potentially combustible materials referred to in the last report had been removed. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents were seen to be supported by competent and qualified staff and to be protected by the recruitment policy and practices of the home, and the commitment to the training of all staff in both general, and learning disability specialist, areas. EVIDENCE: Four weekly staff rotas were received before the inspection, and these demonstrated that there was sufficient staff on duty for the current known needs of this group of residents. A member of care staff agreed to having her staff records used as part of a case tracking exercise, and as well as confirming what had been said by the member of staff undertaking the formal interview in relation to correct procedure taking place during the recruitment of staff, this confirmed with individual times and dates the whole raft of training that had been received in both general and specialist aspects of caring for somebody who has a learning disability. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 19 In the current year she had undertaken sessions with an external trainer in food and hygiene, the safety of medicines, moving and handling, fire safety, depression in care homes, and health and safety awareness, and had received in-house training on dealing with death and dying, techniques in using inhalers, management of epilepsy, and the recording of the administration of medication. She had also completed her NVQ training. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. Quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. A report had been received from a representative of the Staffordshire Fire and Rescue service that indicated to certain aspects of the building as it currently stood, would be unsatisfactory should there be a need to evacuate the building. This together with the need to complete the program or providing guards for radiators compromised the health and safety of the residents. EVIDENCE: The registered manager was not on duty and only attended the home for the session with the representatives of the community nursing team. It was therefore not possible to interview her, but Mrs Elizabeth Adams has substantial experience in running this home, and in responding to the needs of people who have a learning disability. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 21 She has previously been able to demonstrate that she had taken part in recent relevant training to bring her up to date with the most regarded aspects of good practice, and had completed her NVQ Level 4 in Management and Care. During an interview with the administrative officer the inspector was able to view the material collected from such things as residents and relatives questionnaires, and the quality audit. The commission had received comments cards from four sets of relatives, one GP, and a further health and social care professional who had regular contact with the home. None of these contained anything negative, and one professional had stated: The home always phones me immediately if there are any concerns regarding one of the clients she went on to say All my recommendations are always followed up and put clearly into the care plans. This home always works well with other professionals . One set of relatives commented, We think that the staff are of a very high standard in their caring for, and understanding of, the residents . Another set of relatives had said, Always made to feel at home and offered refreshments. (Name of resident) always looks well cared for and tells me of things that they do in the home which is how I know it is so very wellrun . As detailed elsewhere the only thing revealed by the tour of the home was that two radiators still remain in a state where they could be the cause of resident sustaining burns if they were to fall against them. This together with the need to respond to the issues raised by the fire officer is the reason that the outcome in this area being poor. Other than these two issues the standard of the home has always been very good. 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 4 27 4 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 4 3 X 3 X X 1 X 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 13.4 Requirement The program of providing radiator covers requires completion. Two units remain uncovered at this time. The registered person must comply with all the requirements recommendations and observations made by the fire officer in his letter of the 17th of March 2006. Timescale for action 10/12/06 2 YA42 23.4 10/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 8 The Villas DS0000065377.V315441.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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